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Mallampati Score and Sleep Apnea
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Key Takeaways
- Mallampati score is used to determine how difficult it will be to intubate a patient based on their airway, but it can also help doctors assess the risk of obstructive sleep apnea.
- It’s a non-invasive test that measures how much space there is between the base of the tongue and the roof of the mouth.
- There are four scores, and people who score 3 or 4 may have anatomies that make them more susceptible to developing OSA.
- Mallampati score alone is not enough to diagnose OSA, but it can help healthcare providers decide who might benefit from additional testing.
What Is the Mallampati Score?
The Mallampati score is a way of measuring the space within a person’s airway. It’s a non-invasive test, in which a person sits upright, opens their mouth, and sticks out their tongue. The health care provider then provides a Mallampati score based on which anatomical features are visible.
- Epiglottis: The epiglottis is a flap of tissue that covers the airway when a person swallows so foods and liquids don’t get into the lungs.
- Soft palate: The soft palate is the tissue at the back of the roof of the mouth. It moves during talking and swallowing, and it keeps food from entering the nasal cavity.
- Hard palate: The hard palate is a bony area at the front of the roof of the mouth. The hard palate aids in chewing and speaking.
- Uvula: The uvula is a piece of tissue that hangs from the back of the throat. It helps with swallowing and speech.
- Tonsillar pillars: The tonsillar (faucial) pillars are arch-like structures that may be seen on the sides of the back of the throat.
Although originally devised to improve patient safety during procedures involving a breathing tube, researchers found that a person’s Mallampati can also be linked to their risk of OSA and its severity. The original Mallampati scoring system has since been modified. The most commonly used Mallampati scoring system is now referred to as the modified Mallampati score.
Original Mallampati Scoring
The Mallampati score is based on what structures in the mouth and throat are visible to the healthcare provider when a person’s mouth is open and their tongue is shifted forward. The original Mallampati scoring system was developed in 1985. It had three classes.
- Class 1: Tonsillar pillars, soft palate, and uvula can be seen.
- Class 2: Tonsillar pillars and soft palate can be seen, but the base of the tongue blocks the uvula.
- Class 3: Only the soft palate is visible.
Modified Mallampati Scoring
Now, physicians use a modified version of the original Mallampati score that has four classes instead of three. The following scoring system is used to determine a person’s modified Mallampati score:
- Class 1: The soft palate, uvula, and tonsillar pillars can be viewed.
- Class 2: Just the soft palate and uvula are visible.
- Class 3: Only the soft palate and the base of the uvula are visible.
- Class 4: The hard palate is the only structure visible.
Some practitioners also include Class 0, which describes when any part of the epiglottis is visible.
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What Is a Normal Mallampati Score?
A score of 2 or lower on the Mallampati scale suggests that the features of a person’s mouth and throat do not increase their risk of obstructive sleep apnea. This score means that at least the soft palate and uvula are visible during an examination.
However, it’s important to note that having a low Mallampati score doesn’t mean that a person doesn’t have sleep apnea. While having an open airway can help ensure there’s room to breathe, people can still have sleep apnea even with a Mallampati score of 1 or 2. Jaw structure, neck circumference, genetics, age, race, and sex can also factor into whether a person is susceptible to developing sleep apnea.
And while a score of 3 or 4 may indicate an increased risk of sleep apnea, it doesn’t always mean someone has OSA. Originally, the Mallampati score was developed to determine how easy or difficult it would be to intubate a patient. A person with a score of 3 or 4 is more difficult to intubate than a person with a lower score because of their narrow airway. While narrow airways are linked to OSA, they aren’t the only contributing factor.
Can You Diagnose Sleep Apnea by Your Mallampati Score?
A high Mallampati score cannot diagnose obstructive sleep apnea, but it can help doctors identify whether a person’s mouth and airway structure put them at increased risk. Along with other factors, a high Mallampati score may persuade a health care provider that further testing with a sleep study is needed.
When a doctor suspects someone may have obstructive sleep apnea, they’ll typically evaluate a number of factors.
- Risk: Doctors will consider risk factors like sex, obesity, and age when determining who might be at a high risk of OSA.
- Symptoms: A health care provider may suspect OSA when someone reports symptoms of sleep apnea, such as excessive daytime sleepiness, gasping during sleep, early morning headaches, or snoring.
- Coexisting conditions: A number of medical conditions occur more frequently in patients with OSA, including congestive heart failure, high blood pressure, chronic obstructive pulmonary disease (COPD), and end-stage kidney disease.
- Physical characteristics: Doctors evaluate a number of physical features to learn about a person’s risk of OSA, including the size of their neck, waist, jaw structure, and features of their mouth and throat. Assessing the mouth and throat is where the Mallampati score can play a role in diagnosis.
- AHI score:Sleep studies measure how often a person stops breathing during an hour of sleep. The apnea-hypopnea index score shows this measurement. AHI scores can help determine whether a person has sleep apnea and if so, its severity.
A Mallampati score of 3 or 4 could indicate that your anatomy may be more prone to OSA than someone with a lower score, but you’ll need further assessment from a physician and a sleep study. Based on their assessment of a person’s risk factors and individual needs, a health care provider may order an at-home sleep study or one conducted in a specialized sleep laboratory.
How to Improve Your Mallampati Score
Your Mallampati score is based on your individual anatomy, and there’s really no way to change your anatomy without surgery. Your Mallampati score is unlikely to change or improve over time. However, there are other sleep apnea risk factors that you can improve and control.
- Neck circumference: People with neck circumferences greater than 17 inches are at higher risk for developing OSA. Losing weight can decrease your neck circumference.
- Obesity: Excess weight can press on breathing passages and make it harder to get proper airflow. You can lower your OSA risk by maintaining a healthy weight.
- Smoking: Smoking can irritate and inflame your airway, making it harder to breathe.
- Alcohol consumption: Alcohol relaxes your throat muscles, sometimes enough to prevent air from moving through.
- Certain comorbidities: Sleep apnea is a common comorbidity with specific health conditions including diabetes, hypertension, obesity, heart disease, depression, and high cholesterol. You may be able to lower your risk of OSA by treating one or more comorbidities.
Other Tools for Diagnosing Obstructive Sleep Apnea
Physicians use a range of diagnostic tools to help detect and diagnose OSA. If you think you could have OSA, your doctor may use one of the following tools. Keep in mind that many of these aren’t the sole indicator that you have OSA, physicians often use more than one tool alongside the results of an in-person or home sleep test.
- STOP-Bang: STOP-Bang is a simple yes/no questionnaire that can help assess risk factors. It’s an acronym that stands for: Snoring, Tiredness, Observed apnea, high blood Pressure, BMI > 35, Age > 50, Neck circumference > 16 inches, Gender: male.
- Berlin Questionnaire: This is a 10-question assessment that assigns a score based on answers to questions about snoring, fatigue, blood pressure, BMI, age, and gender. Based on your answers, you’ll get an outcome of either high risk or low risk.
- NO-SAS: Similarly to STOP-BANG, NO-SAS is an acronym-based screening tool. The letters stand for: Neck circumference, Obesity, Snoring, Age, Sex.
- ODI: ODI stands for oxygen desaturation index, a tool physicians use to measure how often your blood oxygen level drops during an hour of sleep and for how long.
- Neck circumference: A neck circumference greater than 17 inches can be a risk factor for OSA.
- ESS: The Epworth Sleepiness Scale measures daytime sleepiness through an 8-question assessment that ranks how likely you are to fall asleep in certain daily situations.
Frequently Asked Questions
Can my Mallampati score change over time?
Because your Mallampati score is assigned based on your anatomical features, it’s unlikely to change over time. The scores of 1, 2, 3, or 4 are given based on how much space there is within your airway. Without surgery, this space probably won’t increase. However, you can improve other sleep apnea risk factors by losing weight, getting treatment for comorbidities, quitting smoking, and adjusting alcohol intake.
Does pregnancy change your Mallampati score?
During pregnancy, the size of the airway may narrow and the Mallampati score can increase. In fact, some pregnant people will have their Mallampati scores increase to class 4 in late pregnancy. This may be due to increased fluid and swelling during pregnancy, which narrows the airway.
Although more research is needed, the rate of obstructive sleep apnea may be higher among pregnant people. Narrowing of the airway is one of the most significant physical changes that may contribute to developing OSA while pregnant.
Is Mallampati score the same as Friedman staging?
While Friedman staging and Mallampati score are both tests that assess a person’s airway, they were developed for different purposes and have distinct measurements. The Mallampati score can help providers see if a person’s anatomy is susceptible to sleep apnea, but it was initially created to determine how difficult it will be to intubate someone. It measures how much free space exists in someone’s airway and assigns them a score between 1 and 4.
Friedman staging is a tool used to learn whether a person with OSA is a candidate for sleep apnea surgery. Instead of measuring free space, Friedman staging looks at tongue position, tonsil size, and body mass index (BMI). Based on test results, a person gets a score between I and IV.
Both Friedman staging and the Mallampati score can be helpful tools for providers, but a high score on either or both tests doesn’t always lead to an OSA diagnosis. An in-person or at-home sleep study is necessary for diagnosis.
Is Mallampati score useful for children?
The Mallampati score is particularly useful for children. For every point increase in a child’s Mallampati score, they have a six times higher risk of having obstructive sleep apnea. In contrast, an adult’s risk of OSA only doubles with every point increase in their Mallampati score.
Using the Mallampati score to predict a child’s risk of OSA can be helpful in deciding when a sleep study should be prescribed.
References
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